Application for Local Board Membership

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Local Association

Contact

Dues
Anne Arundel County
John Beachley 410-268-3100
$35.00
Baltimore City, County, Howard
Paul Green  410-685-4625
10% of State dues
Carroll, Allegeny, Frederick, Garrett
G. Brothers 410-876-6414
$30.00
Eastern Shore
Ed Dickerson 410-546-1255
$25.00
Montgomery/Prince Georges
Mary Shultz 301-670-3891
$60.00
Southern Maryland
Doug Ahearn 301-475-5541
$30.00
Trade Name of Firm:
Business Address
TelephoneFaxE-mail
Corporation Officers: #1 #2
                        #3 #4 
Is the principal time devoted to insurance?      Yes       No   
Are all members of the firm actively engaged in insurance?     Yes        No   
What are their other activities and what % of income is derived from that activity?
List companies represented as an Agent:
List Premium Volume for last calendar year
We the undersigned, individual members of the firm or officers of the Corporation as named above, each agree to abide by the Constitution, By-Laws, Rules and Regulations of :  The Independent Insurance Agents of ____________________________________, and to the Code of Ethics of the Independent Insurance Agents of America, Inc. and the Insurance Laws in the State of Maryland, if and when admitted to membership.
Name:_____________________________________________
Name:_____________________________________________
Name:_____________________________________________
Name:_____________________________________________
Date:____________________
References:  IIAM Members:
Name:_______________________________________________________
Agency:______________________________________________________
Phone Number:_____________________
Name:_______________________________________________________
Agency:______________________________________________________
Phone Number:_____________________

DUES ARE NOT REFUNDABLE!
Have you completed your application for State Association Membership.  Click here for the application!